The Rise of Sim­u­la­tion in Health­care

Em­pow­er­ing Clin­i­cians and Pre­vent­ing Harm

Modern Healthcare - - NEWS -


Prac­tice makes per­fect, but there’s no room for er­ror with real pa­tients. Fol­low­ing in the foot­steps of other in­dus­tries that re­quire pre­ci­sion to avoid deadly risk, health­care is in­creas­ingly us­ing sim­u­la­tion to train and as­sess its pro­fes­sion­als.

Sim­u­la­tion com­prises a va­ri­ety of ac­tiv­i­ties, from sim­ple role-play to com­plex high-tech sce­nar­ios, with a shared pur­pose: re­duc­ing er­rors in or­der to im­prove pa­tient safety. That can lead to higher pa­tient and clin­i­cian sat­is­fac­tion, and po­ten­tially re­duce med­i­cal mal­prac­tice claims.

While tra­di­tional physi­cian ed­u­ca­tion has a “see one, do one, teach one” at­ti­tude when it comes to sur­gi­cal pro­ce­dures, such a phi­los­o­phy doesn’t nec­es­sar­ily work in prac­tice, said Dr. Chris­tine Park, pres­i­dent of the So­ci­ety for Sim­u­la­tion in Health­care.

“Our mantra should be ‘See one, sim­u­late many, do a few more, and then teach one,’ be­cause sim­u­la­tion en­hances train­ing ex­pe­ri­ences be­fore we do things in real life,” Park said.

Sim­u­la­tion prod­ucts, in­clud­ing “task trainer” pro­ce­dure mod­els, manikins, com­puter sim­u­la­tion pro­grams and vir­tual re­al­ity sim­u­la­tors, give clin­i­cians and stu­dents a hands-on, re­al­is­tic ex­pe­ri­ence in treat­ing pa­tients with­out

risk­ing pa­tient harm. The So­ci­ety for Sim­u­la­tion in Health­care, a global, non-profit mem­ber­ship group, works to fur­ther and sup­port the sci­ence of sim­u­la­tion through in­dus­try meet­ings, re­search pub­li­ca­tions, pro­gram ac­cred­i­ta­tion and pro­fes­sional cer­ti­fi­ca­tion.

Un­like a real pa­tient, the chal­lenges as­so­ci­ated with a sim­u­la­tion can be ad­justed. While an ex­pe­ri­enced pro­fes­sional may de­sire a mul­ti­fac­eted chal­lenge to learn some­thing new or pre­pare for a dif­fi­cult pro­ce­dure, pro­fes­sors may want to dial down this level of re­al­ity for a first-time trainee, tak­ing a pro­ce­dure step by step or phas­ing in cer­tain risks.

“One of the great ad­van­tages we have at our dis­posal in sim­u­la­tion is the abil­ity to con­trol the level of re­al­ism that cre­ates the most learn­ing,” Dr. Park said. Set­ting the ap­pro­pri­ate “sig­nal-to-noise ra­tio” by ex­pe­ri­ence level helps max­i­mize the trainee ex­pe­ri­ence, she said.


Sim­u­la­tion can save lives and limit pa­tient harm by en­sur­ing physi­cians young and old alike fol­low pro­to­cols and com­plete all the nec­es­sary steps in or­der to safely per­form a pro­ce­dure. In a study of 44 fi­nal-year med­i­cal stu­dents in Frank­furt, Ger­many, those who par­tic­i­pated in a three-day sim­u­la­tion-based train­ing course were found to have more thor­oughly fol­lowed pro­to­cols for CPR and a trauma en­act­ment in com­par­i­son to stu­dents who shad­owed emer­gency physi­cians for three days. Stu­dents who trained on sim­u­la­tors scored an av­er­age of 90% on their abil­ity to com­plete steps re­quired on a stan­dard CPR check­list, while the other stu­dents scored an av­er­age of 62%.

It’s not just stu­dents. Another study found that anes­the­si­ol­o­gists who en­gaged in sim­u­la­tion-based train­ing on how to prop­erly wean pa­tients from car­diopul­monary by­pass per­formed bet­ter in re­al­life pro­ce­dures than those who re­ceived tra­di­tional in­ter­ac­tive sem­i­nars. Sim­u­la­tion-trained physi­cians scored over five per­cent­age points higher when as­sessed two weeks later by se­nior staff on their abil­ity to ad­e­quately com­plete nec­es­sary steps on a tech­ni­cal check­list. Sim­i­lar re­sults were shown five weeks af­ter train­ing.

Re­searchers seek­ing to un­der­stand whether sim­u­la­tion could help im­prove train­ing for ul­tra­sound-guided cen­tral ve­nous catheter can­nu­la­tion, found that 51% of sim­u­la­tion-trained res­i­dents were suc­cess­ful on the first try of can­nu­lat­ing a pa­tient, as com­pared with the tra­di­tion­ally trained group’s suc­cess rate of 37%,

ac­cord­ing to a study pub­lished in the jour­nal of the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges.

Be­yond the ben­e­fits to in­di­vid­ual learn­ers, sim­u­la­tion of­fers op­por­tu­ni­ties to ap­praise team­work and sys­tems, said Dr. Paul Phram­pus, di­rec­tor of the Peter M. Win­ter In­sti­tute for Sim­u­la­tion, Ed­u­ca­tion, and Re­search (WISER) at the Univer­sity of Pitts­burgh Schools of Health Sci­ences.

“Sim­u­la­tion pro­vides a plat­form to ed­u­cate and as­sess mul­ti­dis­ci­plinary teams with re­gard to best prac­tices in team­work and com­mu­ni­ca­tions,” Dr. Phram­pus said. “It also al­lows us to look into the sys­tems of care and eval­u­ate for the po­ten­tial of un­known pa­tient safety threats that may ex­ist in a clin­i­cal prac­tice en­vi­ron­ment.”

Jointly de­vel­oped by UPMC and the Univer­sity of Pitts­burgh Schools of Health Sci­ences, WISER pro­vides ex­pe­ri­en­tial learn­ing and sim­u­la­tion-based ed­u­ca­tion to nurs­ing stu­dents, med­i­cal stu­dents, res­i­dent physi­cians and prac­tic­ing health­care pro­fes­sion­als.

WISER’s dif­fi­cult air­way man­age­ment pro­gram pro­vides ev­i­dence-based ed­u­ca­tion and as­sess­ment to anes­the­si­ol­o­gists, Cer­ti­fied Reg­is­tered Nurse Anes­the­si­ol­o­gists, crit­i­cal care physi­cians and emer­gency physi­cians, al­low­ing them to prac­tice and an­a­lyze how to best deal with pa­tient air­ways that may present dif­fi­culty dur­ing in­tu­ba­tion.

By train­ing on a de­vice that sim­u­lates air­way is­sues, these clin­i­cians can pre­pare for emer­gent sit­u­a­tions they may en­counter when treat­ing real pa­tients, such as dif­fi­culty vi­su­al­iz­ing pa­tient vo­cal cords or dif­fi­culty plac­ing a tube in the pa­tient’s air­way due to a block­age or swelling, Phram­pus said, lim­it­ing ad­verse events that may limit a pa­tient’s abil­ity to breathe. The pro­gram con­trib­utes to UPMC’s low rate of air­way in­ci­dents caus­ing harm to pa­tients be­cause of man­age­ment de­ci­sions or tech­ni­cal fail­ures, ac­cord­ing to Phram­pus.


In ad­di­tion to the ob­vi­ous ben­e­fits for pa­tient safety, ef­fec­tive train­ing pro­grams re­duce fi­nan­cial risk for health­care or­ga­ni­za­tions and their clin­i­cians. Less er­rors can mean less med­i­cal-mal­prac­tice suits, which can mean lower pro­fes­sional in­sur­ance pre­mi­ums.

Med­i­cal mal­prac­tice pay­outs have be­gun climb­ing up­ward since 2012, reach­ing $3.9 bil­lion in 2016.

Con­necti­cut’s pay­out rate per capita is among the high­est in the na­tion. In hopes of re­vers­ing this trend and re­duc­ing risk, Con­necti­cut­based Hart­ford Health­Care sought to im­prove sim­u­la­tion-based train­ing for ob­ste­tri­cians, who are at a par­tic­u­larly high risk for mal­prac­tice suits.

The health sys­tem’s Cen­ter for Ed­u­ca­tion, Sim­u­la­tion and In­no­va­tion (CESI) de­vel­oped a sim­u­la­tion-based train­ing pro­gram that eval­u­ates physi­cian ef­fec­tive­ness in pre­vent­ing shoul­der dys­to­cia, a high-risk la­bor com­pli­ca­tion in which la­bor is ob­structed by the in­fant’s shoul­der. The project uti­lized tech­nol­ogy that mea­sures the amount of force be­ing ap­plied to a sim­u­lated baby, elim­i­nat­ing the sub­jec­tiv­ity of a doc­tor-to-doc­tor eval­u­a­tion.

“Ver­dicts in the state of Con­necti­cut have been steadily in­creas­ing, with some ex­ceed­ing $20 mil­lion,” said CESI Di­rec­tor Stephen Don­ahue. The de­vice has given physi­cians more con­fi­dence in their abil­i­ties, and pro­tected them from pre­ventable risk that can re­sult in law­suits.

About 200 HHC doc­tors and nurses have com­pleted the train­ing since its in­cep­tion, al­low­ing the health sys­tem to limit pre­ventable shoul­der dys­to­cia cases. Since the train­ing was com­pleted in Fe­bru­ary 2015, there have been no mal­prac­tice claims re­lated to the con­di­tion.


Sim­u­la­tion has been grow­ing in pop­u­lar­ity. An AAMC sur­vey cites a 19% in­crease in com­puter sim­u­la­tion at med­i­cal schools be­tween 2003 and 2011, and another AAMC sur­vey found that 83 of 90 par­tic­i­pat­ing med­i­cal schools use sim­u­la­tion at some point across a five-year span of res­i­dency ed­u­ca­tion.

Re­spond­ing to a new gen­er­a­tion of clin­i­cians that yearns for in­for­ma­tion when­ever and wher­ever, Cham­paign, Ill.based SIMnext is cre­at­ing train­ing soft­ware that clin­i­cians can take with them through­out the clin­i­cal en­vi­ron­ment. The com­pany is lo­cated in the Re­search Park of the Univer­sity of Illi­nois Ur­bana-Cham­paign and col­lab­o­rates closely with the Jump Trad­ing Sim­u­la­tion and Ed­u­ca­tion Cen­ter, a col­lab­o­ra­tion be­tween the Univer­sity of Illi­nois Col­lege of Medicine at Peo­ria and OSF Health­care, a Peo­ria-based health sys­tem.

SIMnext has cre­ated Health Schol­ars, an in­ter­ac­tive app that al­lows clin­i­cians to learn new safety pro­to­cols or re­fresh ex­ist­ing tech­niques on a tablet they can take with them to a pa­tient’s bed­side. The app in­cludes cour­ses on in­fec­tion pre­ven­tion, med­i­ca­tion safety and blood trans­fu­sion that sim­u­late pa­tient sce­nar­ios and of­fer guid­ance on how to pre­vent er­rors.

An in­de­pen­dent aca­demic study, cur­rently in peer re­view, has con­firmed that the plat­form al­lows clin­i­cians to ac­quire new skills as fast or faster than tra­di­tional train­ing meth­ods, and at a frac­tion of the ex­pense. The app re­duces clin­i­cian time spent train­ing and in ori­en­ta­tion, re­duces la­bor costs as­so­ci­ated with in-per­son train­ing and helps hos­pi­tals avoid ad­verse events, said Dr. John Voze­nilek, vice pres­i­dent and Chief Med­i­cal Of­fi­cer for sim­u­la­tion at Jump.

New gen­er­a­tions of clin­i­cians are more ac­cus­tomed to “just in time” learn­ing and mo­bil­ity op­tions, Voze­nilek said. Sit­ting in a lec­ture hall is no longer a suf­fi­cient ed­u­ca­tional ex­pe­ri­ence.

“These stu­dents are more chal­leng­ing, but the chal­lenges have stretched our cre­ativ­ity and new tech­nolo­gies have emerged,” Voze­nilek said, not­ing re­cent ad­vances in the use of vir­tual re­al­ity.


En­thu­si­asm for in­no­va­tion is some­times tem­pered by cost con­cerns. As health­care or­ga­ni­za­tions face in­creas­ing cost pres­sures, ex­ec­u­tives are con­sid­er­ing re­turn on in­vest­ment when pay­ing for sim­u­la­tion equip­ment and ser­vices.

While sim­u­la­tion tech­nol­ogy comes at an ex­pense, it can al­low clin­i­cians to train in an ef­fec­tive en­vi­ron­ment that lim­its costly risks to pa­tients. A re­cent Na­tional Coun­cil of State Boards of Nurs­ing (NCSBN) sur­vey found that high-qual­ity sim­u­la­tion ex­pe­ri­ences could be sub­sti­tuted for up to half of tra­di­tional clin­i­cal hours across pre­li­cen­sure nurs­ing cur­ricu­lum, given ev­i­dence of the ben­e­fits of sim­u­la­tion.

Health sys­tems go­ing at risk un­der value-based care agree­ments will be hard-pressed to find a more ef­fec­tive op­tion for train­ing their physi­cians and nurses to im­prove qual­ity and re­duce ex­pen­sive er­rors, Voze­nilek said. A Mayo Med­i­cal School meta-anal­y­sis of 289 re­search stud­ies con­cluded that sim­u­la­tion­based ed­u­ca­tion is in­deed ef­fec­tive.

“The pres­sures on health­care to­day to con­tin­u­ously im­prove qual­ity while re­duc­ing cost will make tra­di­tional train­ing ob­so­lete,” Voze­nilek said. “Scal­able, af­ford­able plat­forms such as these which have a demon­stra­ble ROI are go­ing to rad­i­cally change the tra­di­tional model for pro­fes­sional de­vel­op­ment and learn­ing.”

To cal­cu­late the to­tal value of sim­u­la­tion ini­tia­tives, it is im­por­tant to weigh both short-term and long-term ben­e­fits, ex­perts say. By em­pow­er­ing physi­cians to be more con­fi­dent in their abil­i­ties, con­sis­tent sim­u­la­tion­based train­ing can im­prove clin­i­cian sat­is­fac­tion and re­duce em­ployee turnover. Clin­i­cians are fond of sim­u­la­tion: a re­cent sur­vey showed that 78% of emer­gency room per­son­nel rated sim­u­la­tions as ex­tremely valu­able or valu­able.

It can be some­what dif­fi­cult to prove ROI in sim­u­la­tion train­ing, but ex­perts agree it’s even harder to put a price on pa­tient safety.

“En­light­ened or­ga­ni­za­tions will look be­yond direct ROI on the per pro­gram, or per course ba­sis, and rec­og­nize that there is a sig­nif­i­cant value pro­vided through the in­vest­ment in sim­u­la­tion,” Phram­pus said.

Photo Credit: Ed Rieker Pho­tog­ra­phy

Photo Credit: Hart­ford Health­Care

Photo Credit: Ed Rieker Pho­tog­ra­phy

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